Integrated management of an ongoing tuberculosis outbreak in a U.S. born homeless population in Indianapolis, IN

Background: In 2009, the TB case rate in foreign-born persons was approximately 11 times that of U.S. born persons. In contrast, that same year an outbreak of Mycobacterium tuberculosis was identified among U.S. born homeless in Indianapolis, Indiana. All matched a unique genotype, IN0074. By the end of 2010, 20 active TB cases had matched IN0074. Methods: Challenges to controlling TB among the chronically homeless are widely recognized. Case management is often complicated by client factors such as: use of congregate settings; high incidence of substance abuse and mental illness; lack of a medical home; and general mistrust of authority or government. Traditional TB control strategies, while important, may require integration of population specific measures for successful treatment outcomes. The need for flexibility, creativity and sensitivity are paramount. Findings: We will discuss integrated, non-traditional measures being applied in the management of an ongoing TB outbreak among the homeless. Our success includes a 100% treatment completion for eligible TB cases. The focus will be on innovative laboratory, medical and collaborative measures, as well as the success and challenges encountered. Topics discussed will include: the role of genotyping; Interferon Gamma Release Assays (IGRAs); mechanisms for information sharing with community and healthcare partners; Directly Observed Preventative Therapy (DOPT); and short-course therapy for latent TB infection. We will highlight the critical role of positive client/provider relationships when working with vulnerable homeless populations.